CHILDREN’S SERVICES REFERRAL FORM

Date of Referral Referrer

SERVICE YOU WISH TO REFER TO (Please see attached sheet for addresses of local services)
Primary Care Services Children’s Disability Services
Children with non-complex needs should be referred to Children with complex needs should be
Primary Care. Copies of referral forms will be forwarded to referred to Children’s Disability Services
all selected disciplines. A child has complex needs if he or she has a
range of significant difficulties that require
Dietetics Physiotherapy Speech & Language Therapy the services and support of a disability team.
Occupational Therapy Social Work Psychology
Children’s Disability Network Team
Community Medicine Service Nursing
Other (specify) ___________________

CHILD’S PERSONAL DETAILS

Surname First name

Gender Date of Birth Child’s Age Years Months

Address Eircode

Parent/Guardian 1 Name Parent/Guardian 2 Name

Relationship to child Relationship to child

Telephone Mobile Email Telephone Mobile Email

Address (If different from the child’s) Address (If different from the child’s)

Country of Birth First Language Interpreter required

YES NO
Other languages spoken at home

Number of siblings, their ages and details of any services they are attending

REASONS FOR REFERRAL

What are the main 1.

concerns and
priorities for the
child and their
family? 2.

3.

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GENERAL PRACTITIONER DETAILS

GP Name/Practice GP Telephone Email

GP Address

OTHER COMMUNITY HEALTHCARE SERVICES List all other services currently involved or waitlisted
Children’s Disability Network Team Primary Care: Speech and language therapy
Occupational therapy Physiotherapy Psychology
Other (please give details)

Child & Adolescent Mental Health Service Tusla

Other (Please give details)

CRECHE, PRE-SCHOOL OR SCHOOL DETAILS ( Attach any Preschool or School Reports)

Creche Preschool School Child’s Class

Address Address

Manager/Contact Person Principal’s Name

Telephone Email Telephone Email

MEDICAL HISTORY (Attach any relevant Medical Reports)

Relevant Medical History & Birth History

Any diagnosis e.g. medical condition, learning disability, developmental disorder, hearing impairment.
There may be more than one. Who made the diagnosis and date?

If the child is currently in hospital what date is he/she expected to be discharged?

Current medications

Allergies/Adverse medication events

Current investigations e.g. blood tests, scans, hearing tests

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SOCIAL CIRCUMSTANCES
Relevant family and social history
For example family health or housing difficulties, financial or employment problems, bereavement or other
stresses.

ANY OTHER RELEVANT INFORMATION

Please indicate whether referrer should be contacted prior to the initial appointment YES NO

Are there any relevant risk factors in relation to this referral?

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CONSENT: Referrals without signed consent of parent(s) / guardian(s) will not be accepted.
It is required by law that at least one of the child’s legal guardians consents to the referral and signs this
form. It is advisable that both parents/legal guardians are aware of this referral.

Definition of a Legal Guardian

All mothers, whether they are married or unmarried, have automatic guardianship status in relation to their children,
unless they give the child up for adoption. A father who is married to the mother of his child also has automatic
guardianship rights in relation to that child. This applies even if the couple married after the birth of the child.

A father who is not married to the mother of his child does not have automatic guardianship rights in relation to that
child. If the mother agrees for him to be legally appointed guardian, they must sign a joint statutory declaration.
However an unmarried father is automatically a guardian if he has lived with the child's mother for 12 consecutive
months after 18/1/2016, including at least 3 months with the mother and child following the child's birth.

Children in Care
For children in voluntary care or on an interim order, the parents must sign the consent. For children on a care order the
consent is signed by a Tusla Child and Family Agency social worker.

Child’s Name Date of Birth

 I give permission for my child to be referred to Primary Care Services /Children’s Disability Services.
YES NO

 I give permission for information about my child to be held by Primary Care Services/Children’s
Disability Services in accordance with obligations under the Data Protection Acts 1988, 2003 and
2018 YES NO

 I give permission that in the event that this referral is not appropriate it may be shared with other
relevant services to facilitate an onward referral. I will be contacted in advance of this information
being forwarded on to another service. YES NO

 I give permission to Primary Care Services/ Children’s Disability Services to contact and obtain
relevant information in order to understand and address my child’s needs from the professionals and
services listed below, such as a hospital consultant, psychologist, speech & language therapist,
teacher etc. Only those listed below will be contacted. YES NO

Name (if available) Service Contact Details

Name of Parent 1/Guardian

Signature

Date:
Name of Parent 2/Guardian

Signature

Date
REFERRERS DETAILS
Name: Date:
Role (Parent/ Legal guardian, professional):

Address: Telephone: Mobile:

Email:
Signature:

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